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Please check one: New Addition <br /> JOB SITE <br /> Owner's Name 4. (fe�� zT, Telephone Number <br /> Mailing Address It) - ,�"uj LiQ S <br /> Sprinkler Contractor's Name Telephone Number y y/-Ili <br /> Contact Person <br /> Mailing Address `► R- � i <br /> WATER SUPPLY �a A,- sS 3 <br /> Lake Well City <br /> BACKFLOW DEVICE <br /> AVB PVB RPZ <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers - <br /> - <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surcharge. $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ o <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees <br /> to do all work in strict accordance with the ordinances of the City and State regulations, and <br /> certifies that all statements made on this application are complete, true and correct. <br /> Applicant Zr Date �I <br /> . . . . . . ... <br /> Approved Approved with Corrections Denied <br /> Reviewed b <br /> Date �/`�&)L! <br />